SUMMARY
Aim: To determine ethical issues between nurse and physician interprofessional communication in clinical professional practice.
Methods: A descriptive cross-sectional study was conducted at Başkent University Ankara Hospital as a private hospital in Turkey. Descriptive statistics, Student’s 𝑡-test, Chi-Squared (χ²) test, and Pearson correlation were used. Variables with a p-value < 0.05 were considered as statistically significant.
Results: The response rate of the study was 80%. The main results of the study showed that physicians are more satisfied than nurses with their relationship. The majority of nurses (49,29%) responded positively to physician-nurse collaboration is characterized by cooperation comparing with physicians (45,36%) (p=0.021). Moreover, physicians perceived that there were good human relationships and positive interactions with nurses (38.57%), and nurses (35,36%) confirmed this perception. The analysis was done by the vast majority of both female professions.
Conclusions: The analysis of the results showed that an essential element for collegiality and the development of teamwork relationships is the ability to cooperate with representatives of other professions. Nurses' and physicians' perceptions of their interpersonal communication have been indicated to have a significant impact on job satisfaction and the relationship among them characterized by cooperation'' was appreciated by both by physicians and nurses. And also It was determined that the significant correlation between profession, age, and working year.
Keywords: Ethical challenges, medical ethics, physician-nurse relationship, professional collaboration, patient-centered care
LIST OF TABLES
Table 1: Socio-demographic characteristics of respondents. ... 34
Table 2: Socio-demographic characteristics of respondents between department and profession ... 35
Table 3: Socio-demographic characteristics of respondents between profession and working year ... 35
Table 4: Mean scores for individual items on physician and nurse respondents’ perception of the nurse-physician relationship ... 40
Table 5: Relationship between profession and statements ... 48
Table 6: Relationship between gender and statements ... 49
Table 7: Relationship between age and statements ... 50
Table 8: Relationship between working year and statements ... 50
Table 9: Relationship between department and statements ... 51
Table 10: Relationship between level of education and statements ... 53
LIST OF FIGURES Figure 1: The relationship between profession and gender ... 36
Figure 2: The relationship between profession and level of education ... 36
Figure 3: The relationship between profession and working year ... 37
Figure 4: The relationship between profession and age ... 37
Figure 5: The relationship between gender and working year ... 38
Figure 6: The relationship between working year and age ... 38
Figure 7: Respondents' opinion on the statement ''The nurse-physician relationship is superior- subordinate'' ... 41
Figure 8: Respondents' opinion on the statement ''The relationship between female nurse and male physician is better than that between male nurses and male physician.'' ... 42
Figure 9: Respondents' opinion on the statement ''Physician approaches to nurse decrease their self-confidence'' ... 42
Figure 10: Respondents' opinion on the statement ''Physician ignores valuable suggestions offered by nurses'' ... 43
Figure 11: Respondents' opinion on the statement '' Physician insults nurse at any time and place with no limit better their relationship'' ... 43 Figure 12: Respondents' opinion on the statement '' Physician always deals with nurse in informal way'' ... 44 Figure 13: Respondents' opinion on the statement '' There is always discussion between nurse and physician.'' ... 44 Figure 14: Respondents' opinion on the statement ''Not understanding nurse’s and physician’s problems leads to bad relationship between both.'' ... 45 Figure 15: Respondents' opinion on the statement ''The relationship between nurse and physician affects their job satisfaction'' ... 45 Figure 16: Respondents' opinion on the statement '' Physician is keen to read nurse’s note in patient record.'' ... 46 Figure 17: Respondents' opinion on the statement '' There is human relationship between nurse and physician.'' ... 46
ACKNOWLEDGEMENT
I would like to express my deepest gratitude to my supervisor Assoc. Prof. dr. Eimantas Peičius, and my consultant Prof. dr. Aurelija Blaževičienė, for her useful guidance, insightful comments, and considerable encouragement to complete this thesis. Without their support and guideline, this research would not have been completed.
And also, I would like to extend my sincere thanks to all those who have supported me including Prof. Dr. Gaye Ulubay, Software Engineer Enes Kaan Korukluoglu, MSc. & Energy System Engineer Yalım Gültekin, Dr. Sevgi Can Cengiz, Ph.D. student Tugce Yerlitas ISM University of Management and Economics, Certified Translator Bora Cil, Civil Engineer Giray Ismetoglu at General Directorate of Highways, DSI General Directorate Foreign Affairs Chief Consultancy Staff Hasan Basri Yüksel. Besides, I wish to express their appreciation to my university teachers for providing their expert views.
I would also want to send my appreciation to all the research participants. Without their valuable opinions and ideas on the questionnaires, the research would not have been accomplished.
Last but not least, I would like to express my indebtedness to my parents who have given me constant support and love during the completion of the thesis
Merve Korukluoglu
TABLE OF CONTENTS
SUMMARY ... 2
LIST OF TABLES ... 3
LIST OF FIGURES ... 3
ACKNOWLEDGEMENT ... 5
ABBREVIATIONS ... 8
INTRODUCTION ... 9
Relevance of the study ... 10
Novelty of the study ... 10
AIM AND OBJECTIVES ... 11
1. REVIEW OF LITERATURE ... 12
1.1. Public Health and Professional Relationship ... 12
1.2. Interprofessional Collaboration and Ethical Issues ... 19
1.3. Medical, Legal and Ethical Issues in Nursing ... 24
1.4. Perception of Ethical Issues by Physicians and Nurses ... 25
1.5. Association Between Nurse-Physician Collaboration and Patient Outcomes ... 29
1.6. Empirical Research in Medical Ethics and Collaboration ... 30
2. METHODOLOGY ... 32
2.1. Design, Setting, and Period of Study ... 32
2.2. Sample and Sampling ... 32
2.3. Research Instrument ... 32
2.4. Statistical Data Analysis ... 33
2.5. Research Ethics ... 33
3. RESULTS ... 34
3.1. Socio-Demographic Characteristics of Respondents ... 34
3.2. Differences in Mean Value Evaluating Professional Relationship ... 36
3.3. Ethical Issues in Physician-Nurse Relationship ... 39
3.4. Physicians’ and Nurses’ Attitudes on Interprofessional Communication ... 41
3.5. Correlation Coefficient Based on Statements among Characteristics of The Participants ... 47
4. DISCUSSION OF RESULTS ... 54
CONCLUSION ... 58
RECOMMENDATIONS ... 59
REFERENCES ... 60
ANNEX 1- The Approval of Bioethics Center at LUHS ... 70
ANNEX 2- The Approval of Chief Physician at Başkent University Ankara Hospital ... 71
ANNEX 3- Permission of Author of The Questionnaire ... 72
ANNEX 4- The Research Questionnaire ... 73
ABBREVIATIONS
ANA: American Nurses Association
CDC: Centers for Disease Control and Prevention CHCs: Community Health Centers
CNR: Council of National Representatives FHCs: Family Health Centers
FPs: Family Physicians
HASUDER: Association of Public Health Specialist ICN: International Council of Nurses IPC: Interprofessional Collaboration
KETEM: Cancer Early Diagnosis, Screening and Training Centers MOH: Ministry of Health
MPH: Master of Public Health MSc: A Master of Science PH: Public Health
PHC: Primary Health Care PHD: Physician of Philosophy PHN: Public Health Nursing PHS: Public Health Specialist
INTRODUCTION
In today’s complex healthcare environment, it is crucial for all members of the healthcare team to work together in a collaborative, collegial manner in an effort to provide the best patient care (1). The interprofessional collaboration between physicians and nurses is important and has been highlighted in different contexts (2), such as cooperation in work, carry out plans for patient care. Collaboration, between physicians and nurses, refers to working together for a common purpose to achieve patient care quality and it is also good for patients.
In the meantime, it ensures effective cooperation and communication, comprehensive care, and patient-centered decision.
The World Health Organization stated that nurses are collaborating effectively with other health care professionals for taking care of patients. Besides physicians, nurses work closely with other nurses, physiotherapists, dietitians. Today in many hospitals provide the patient's care and treatment by the members of the team (3).
Nurses and physicians play a major role in patient care. The role, between physicians and nurses, can improve patient outcomes, increase job satisfaction and quality care. Also, the benefits of impressive physician and nurse relationships can increase better patient care, also decreased patient mortality, morbidity, and medical errors. Besides this, the physician-nurse relationship is stressful on one hand and based on teamwork other hands. Due to some differences in power and status among physicians and nurses, physicians and nurses disagree on a patient's treatment plan. Traditionally, the profession of medicine has emphasized expertise, autonomy, and responsibility more than interdependence, deliberation, or dialogue (4).
Interprofessional collaboration in Turkey is ideally placed in health care has an essential role in the continuity of care to increasing healthcare access, quality of care (5). Turkey, like other countries, physicians are at the top of medical practice. For this reason, structuring the health system around physicians reinforces the unequal working relationship between nurses and physicians emanating from differences in their education, socio-economic status, and professional duties, privileges, and responsibilities (6).
Effective cooperation between physicians and nurses in the health system contributes to the quality of patient care and will also improve effective communication, decision-making, and shared responsibility. Moreover, interpersonal relations affected by cultural norms which
include attitudes and expectations in the health care systems. Also, it has been argued that in some societies and nurses have less autonomy than physicians. This became a hierarchical problem and it developed with the adversarial relationship between the two professions (7).
Besides, nurses feel like they have less autonomy and respect. In the relationship with the physician, the nurse becomes passive. Furthermore, from point of nurses' view, they thought negatively about cooperation and communication rather than physicians, which lead to developing this attitude (8).
Interprofessional collaboration is an important factor in the care of patients also in the health care system. In the absence of collaboration, patients' outcomes are negatively influenced. Furthermore, physicians and nurses need to ensure they have confirmed the agreement on planned care. The study is designed to reveal the most important issues of the interprofessional relationship between nurses and physicians, to propose practical recommendations for future health care decision-makers on how to improve organizational culture in health care services.
Relevance of the study: This study was designed to find out explore the ethical challenges of interprofessional collaboration in clinical practice. Understanding the issues that affect collaboration, as well as the historical background in which it has developed in Turkey, can help nurses and physicians in their collaborative effort to enhance health care delivery. Usually, psychological aspects and professional issues in the process of physician-nurse working relationships are analyzed. However, this study also emphasized ethical aspects which is important from the perspective of management and public health. The survey in the research attempts to understand the overall perceptions of ethical issues by physicians and nurses in Turkey.
Novelty of the study: Despite the importance of collaboration between physicians and nurses recognized is globally worldwide, some ethical issues among them present in the everyday practice of health care. Besides, there are limited sources and data was available regarding ethical issues of physicians and nurses in Turkey. This study is not only aimed to determine ethical issues between nurse and physician interprofessional communication in clinical professional practice but also emphasized the perceptions and awareness of both professions are important for their codes of ethics, which supply standards of professional conduct and guiding principles.
AIM AND OBJECTIVES Aim:
To determine ethical issues between nurse and physician interprofessional communication in clinical professional practice.
Objectives:
1. To disclose the main ethical issues in the interprofessional relationship between physicians and nurses.
2. To reveal the perceptions of nurses and physicians towards nurse-physician communication in tertiary care.
3. To determine the correlation between respondents’ perceptions of professional collaboration and their socio-demographic characteristics.
1. REVIEW OF LITERATURE
1.1.Public Health and Professional Relationship Essential Components of Public Health
The field of Public Health (PH) is broad and plays a major role in populations around the world. According to the World Health Organization, PH is characterized as the science of preventing disease, extending life, and promoting health through society's coordinated efforts (9). PH is a dynamic and one of the important parts of the health systems (10), also the underlying goal of public health is to improve the existential issues that affect health. Thus, it helps better health outcomes and increases everyone’s quality of life by promoting a healthy environment.
PH is directly associated with promoting the entire population of nations and states of health rather than individual health in both developed and developing countries (11). Because having a population-based approach supports health promotion with public health activities, policies, implementations from the community level up to the global level (12).
Within the past few decades, PH and has efficiently become crucial in the health sector.
To enhance and use widely, Beaglehole and Bonita et. al (1997) defined the essential elements of modern public health theory and practice:
• collective responsibility
• prime role of the state in protecting and promoting the public’s health
• partnership with the population served
• emphasis on prevention
• recognizing underlying socio-economic determinants of health and disease
• identifying and dealing with proximal risk factors
• multidisciplinary basis for action (13).
Describing essential elements of public health can identify how to make an efficient design system and deliver action programs based on supporting health throughout the system functioning effectively (14). On the other hand, these essential components express specified competencies that all professionals need in that field. Herewith, these elements enhance the effectiveness of the health system across the world (15)
The first international conference Ottawa Charter emphasizes health promotion to increase
promotion at the global level that controls public health issues. Besides, there are many public health agencies are responsible for both health promotion and disease prevention at the national level regarding modern public health (17).
In terms of Turkey, public health is conducted with The General Directorate of Public Health in Turkey under the MOH. In addition, Turkey has adopted a holistic approach to health care, and this is one of the most important elements in public health. Another significant point is improving the equal public health status within the country (18).
To summarize, public health improves the health of individuals and communities.
Having knowledge of the essential components of public health can increase better health outcomes for all countries.
Public Health and The Role of The Public Health Specialist
PH is global, and it must have a multidisciplinary approach through life. Not only it encompasses so many different areas but also these areas can enable several different public health careers to exist, such as epidemiologists, public health physicians (PHS), public health nurses (PHN), health educators and community health workers, public relations specialists who support the main target to effectively protect, promote and improve the public's health worldwide (18). Also, this multidisciplinary approach, it offers unlimited opportunities for professional specialization. Because it is necessary to maintain a high level of professionalism to state population health (19). Herewith, it requires essential knowledge and skills with the discipline by professionals to enable optimal health for all people.
Specializing in PH addresses professionals to focus on their interests and passion, gain in-depth knowledge to reach out expertise in the future life, and also explore the frontier of science (20).
PHS are trained professionals who enhance to create better circumstances for people's well- being and raise awareness about being healthy (21). Thus, they play a prominent role in the consideration of the population to improve health.
The conceptual framework for professional education covers the main health professions such as medicine, nursing, and dentistry. But identified all these professions took part in different academic models or careers in medical and healthcare fields. According to most professions, most people define themselves as PHS when they practice public health in some parts of their work-life such as medicine, nursing, dentistry, and so on (22). However, being a PHS is a distinct profession that has to have higher qualifications in public health, take a more
comprehensive overview course or program, and gain public health practice experience encompass the skills and knowledge. (23) Nevertheless, this variety of backgrounds of education enable to thoroughly integrate practice skills into public health. So, this emphasizes the understanding of PH why it is important in the work area.
For the professional position, A Master of Public Health (M.P.H) and a Physician of Philosophy (Ph.D.) in Public Health are necessary provided to widen and deepen the knowledge with related disciplines. While physicians and nurses are front-line workers to protect against disease, graduates who completed MPH and Ph.D. in PH can dedicate which treatment is useful or not. They can create approaches to give support. Moreover, they can transfer their transdisciplinary knowledge into effective and public health interventions (24).
Throughout the history of public health, the name of the PHS differs by each country. In the USA, some European countries, England (25) and Turkey are still used as public health specialists, but meanwhile, Russia and Germany have a different name for this profession (26).
In the world, though the requirements for a PH career may differ based on the profession and education. In Turkey, for physicians who want to advance in a career in PH, there are two fundamental options. The first one is that after graduation, physicians can work as a PHS with public health specialty training. This is important to have knowledge about the specific field.
The second one is that after physicians started to work in primary care health services, they tend towards public health. Furthermore, they are willing to get a master's degree, then pursue a career in a doctorate degree. According to available data, most of the physicians who prefer to work in public health have to take a special exam which is defined as Turkish Medical Residency Exams (TUS) (27). Addition to this, Association of Public Health Specialist (HASUDER) describes PHS as a physician who knows the health problems in the society, creates PH policy to produce a solution, and monitor and evaluate PH policies (28). Hereby, PHS can work in community health centers, hospitals, infection control committees, occupational health units, ministry of health, international organizations (e.g., WHO, United Nations) and can work as health manager, advisor, researcher (29).
In Turkey, in the early years of nursing education was three years of practicing at the high school level was very crucial for nursing preparation before becoming a professional. Today, all nurses have to study and completed four of year nursing program at the university level. For nurses who want to advance in a career can continue education life by doing a Master of Science
departments for nurses: Fundamentals of Nursing, Medical Nursing, Surgical Nursing, Women’s Health and Gynecology Nursing, Pediatric Nursing, Psychiatric Nursing, Public Health Nursing, and Nursing Management (30).
Public health nursing (PHN) is a special field like other fields of nursing especially at the master’s level then-doctoral level, and it is a part of undergraduate nursing education and it puts emphasis on population health. But the education of PH in Turkey exists only for one semester and it is not enough to cover all aspects of PH. The content of PH must be revived and strengthened. Hence, to have the knowledge and learn all the essential components of public health is really important to develop PH in Turkey. On the other hand, PHN in Turkey was identified within ‘Regulations on the Execution of Services in Regions where Health Services have been Socialized’, based on Law no. 224 in 1963. According to this regulation, it was clarified roles and responsibilities of PHN. Thanks to this, they can work as home care nurses, mother and child health and family planning center nurses, community mental health center nurses, occupational health nurses, school health nurses, and penitentiary nurses (31). To point out, it is important that the title of PHN must indicate with postgraduate education and various certificate programs, as in many countries.
To summarize, as well as throughout the world, the field of PH plays a significant role in Turkey. In many countries, physicians and nurses have the title of ‘PHS’. But in Turkey, the biggest difference between physicians and nurses is the different titles for the same field. While physicians work as PHS after completed exams and training, nurses work as PHN. Especially, in an era of increasing challenges for public health, physicians and nurses have the potential to make a dramatic difference and they both play a major role. Thus, to understand the role of PH, it is important to consider the essential components of the profession.
Public Health Challenges Facing in Turkey
PH has an impact on the health of many people, and it contains population-based activities to prevent disease, promote health for keeping the nation healthy. PH challenges in today's rapidly changing world have a huge impact on the population and the great majority has been affected despite the rapid medical advances and technological development. Most commonly, these diversifications, findings, and results can change depending on the country.
The Centers for Disease Control and Prevention (CDC) published a list of threats to PH, some examples include alcohol-related harms, tobacco use, increased rates of obesity and physical inactivity, heart disease-stroke, healthcare-associated infections, and so on (32). When a PH
concern has been identified, PHS and medical professionals must gather together to develop preventive strategies and establish a comprehensive approach.
Despite achieved impressive health gains in nearly many countries, also Turkey is facing some PH problems. The prevention, control, and management of many of these challenges require a population-wide intervention (33). The public health challenges can be summarized in the following headings:
• Tobacco use
Tobacco smoking is one of the world’s major PH problems. According to data, Turkey has the third place in cigarette consumption among European countries and the seventh place in the world (34). Besides, Turkey is the first country in the world that has accomplished all WHO’s six MPOWER tobacco control measures (Monitor, Protect, Offer, Warn, Enforce, and Raise taxes). Although Turkey has made more comprehensive implementation of tobacco control policies, smoking continues to kill many people, and it is still a public health problem (35). At this point, healthcare professionals play an important role in tobacco control. They have the potential to protect society from the harmful effects of smoking.
The WHO stated the 5A (Ask, Advise, Assess, Assist, Arrange) model based on smoking cessation (36). The role of physicians is highly effective in smoking cessation in patients is important by using this model. Because they encourage patients who have quit smoking and decrease the death rate from smoking. Besides physicians, the WHO indicated that nurses have a key role in health protection. Herewith, their nursing functions are divided into four fundamental groups such as direct care, health education, consultancy, and research. They can use the role of health education and consultancy to make a positive effect on patients’ life who want to quit smoking (37).
To summarize, tobacco use in Turkey continues to exist in significant health. Physicians and nurses play a major role in health promotion and smoking prevention. Also, identifying the level of implementation of tobacco prevention and control policies and increasing cessation units will be remarkably effective to decrease the death rates.
• Obesity
Obesity is one of the most important public health issues in the world. It is a chronic, progressive, and life-threatening disease. Over the last few decades, obesity is increasing in
both developed countries and developing countries have been affecting (38). In Turkey, the increasing prevalence of obesity is higher than in European countries (39). On the other hand, obesity is mostly observed in both adults and children and this situation is serious. Especially the prevalence of childhood obesity has increased as an alarming situation. Therefore, there are some measurements to take including public health education, increasing physical activity, and a healthy diet.
In recent years, the Turkish health authorities have been aware of the obesity problem and it is a potential threat to public health. The MOH of Turkey had implemented to address obesity as an increasing public concern. '’The Obesity Prevention and Control Program of Turkey 2010- 2014’’ is adopted by governments to decline the prevalence of obesity (40). Besides public health policies and implementation, it must be conducted by multidisciplinary teams such as physicians, dietitians, and nurses must make big steps to identify an effective treatment for patients by using medical assessment, management, counseling, dietary therapy, behavior therapy (41).
To summarize, obesity is a widespread public health problem in the world. This situation in both adults and children in Turkey has substantially increased. It is necessary to take precautions supporting by health education, creating guidelines for preventing obesity, implementing policies. The physicians in Turkey support the patient, enabling them to take incremental steps toward better health and fight against obesity. Additionally, the nurses help patients improve their diets and eating habits. And nurses' and dietitians' collaboration have positive effects on patient outcomes. This multidisciplinary collaboration has the responsibility to prevent obesity and it is essential in providing the best care possible to patients and improving health care outcomes.
• Cancer
Cancer is the second most common cause of death after cardiovascular disease, and it is one of the major public health issues worldwide. Each year, tens of millions of people are diagnosed with various types of cancer and living with this (42). According to data from the WHO, tobacco use, physical inactivity, alcohol use, dietary factors, overweight and obesity, and inadequate fruit and vegetable consumption are the main factors that increase the risk of cancer (43). In Turkey, cancer incidence and mortality rates have been increasing.
Determination of cancer incidence and mortality data is very crucial for controlling cancer and prevention, early detection, diagnosis, treatment. Because all these gathered data may influence
public health measures. One study showed that cancer-related deaths increased by 28% in 2018 when it is compared to 2009 (44).
Each type of cancer has its own characteristics, risk factors, causes, and treatments. Hence, WHO suggests screening programmes detect early signs and stages of cancer (45). The early diagnosis and screening programmes in Turkey are conducted by Cancer Early Diagnosis, Screening and Training Centers (KETEM). KETEM is affiliated with the Community Health Centers (CHCs). Today, the CHSs are a part of the primary health care services in Turkey.
These centers brought together multidisciplinary teams such as family physicians (FPs), nurses (46), midwives, x-ray technicians, and medical technicians. They are responsible for protection and screening programmes.
What is more, FPs have some fundamental functions in cancer screening program such as explaining the programme to society and increasing awareness to participate, inviting the target population, and informing about the screening test results to them (47). Upon hearing a diagnosis of cancer, the patients face many issues including diagnosis, treatment. At this point, nurses play a crucial role in the process of easing patient’s problems. Thus, nurses are key people in the delivery of health services. They have some fundamental functions as family practitioners: taking care of the patient's physical needs, carrying out counseling cancer screening programs and follow up the treatment, cancer prevention, giving health education to patients and families (48).
To summarize, cancer is an ongoing public health issue in developed countries and an emerging concern in developing countries. In Turkey, cancer screening is conducted by KETEM, CHCs, and family health centers (FHCs). Mainly FPs and nurses are responsible for cancer prevention and control programmes. It shows that collaboration between physicians and nurses may have a positive impact on patient's life and better health outcomes.
1.2.Interprofessional Collaboration and Ethical Issues Interprofessional Collaboration in Health Care
Science and knowledge are fundamental for a health care profession to exist and progress for further research. Nowadays, the word interprofessional is more often used in the literature to describe how professionals from various disciplines communicate and make decisions together, which is a key distinction from multidisciplinary (49). According to the Canadian Interprofessional Health Collaborative, interprofessional collaboration (IPC) is defined as a ‘partnership between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues. It is important to note that acting as a profession has a positive effect on the quality of care. There has been a global interest during the last few decades, concerning why interprofessional collaboration should occur in health care, and this issue is not new or unexplored in the searching area. IPC has been emphasized as a strong and significant force because of high-quality health care outcomes (50).
In health care, it is generally believed that collaborative efforts provide better health services which are characterized by ongoing interaction and outcomes for the populations that are served. Evidence suggests that interprofessional teams provide a more clinically effective service, supply much better health outcomes, and are more patient-centered care. Also, collaboration among healthcare workers has been shown to improve patient outcomes such as reducing preventable adverse drug reactions (51), improve the quality of healthcare services.
To summarize, there is a strong interaction between effective team collaboration and the quality of healthcare outcomes. Also, it is important to understand that what IPC and how it really works.
Historical Background of Nursing
Historically, Florence Nightingale was known as the 'lady with the lamp' the founder of modern nursing of professional nursing and had the strongest impact on the field of nursing and healthcare. Nightingale’s most famous contribution occurred during the Crimean War in 1854 (52). Florence noticed that the health status in military camps of Britain soldiers was destroyed during the war. She examined injured soldiers who were left on the floor and the few physicians were trying to give patients care with basic facilities, in dirty environment conditions. She tried to create a clean environment with some medical pieces of equipment and with clean water. As
a result of her intervention, the mortality rated decreased from 60% to 42% and then 2, 2%
respectively. After she stated and included some notes in Nursing including ethical admonitions such as listening to patients, upholding confidentiality, and putting patients' needs first. She highlighted the importance of building a trusting relationship with patients and she believed that communication is the key factor of being professional (53).
The Nightingale Pledge, an adaptation of the Hippocratic Oath, was written under the chairmanship of Lystra Gretter in 1893, was used for graduate nurses at the Harper Hospital in Detroit, Michigan. The pledge has some functions based on a common set of nurses’ goals to do their duties following certain ethical principles. The pledge was also intended to define and form nurses' perceptions of what they did with the meaning of the principles according to their historical period. The Florence Nightingale Pledge was created as a mark of respect for the founder of modern nursing (54).
The Code of Ethics
The word ''ethics'' derived from the Greek word ''ethos'' which means it is custom or habit. They combine to explain to interact with each other. The definition of ethics is broad, but The Encyclopedia Britannica defines the definition of ethics: “The discipline concerned with what is morally good and bad, right and wrong” (55) and also including the systematic study of conduct based on moral principles and reflective choices. Ethical values are universal rules and indicate the essential importance of determining what kind of action or purpose is valued. Ethics are moral principles that how to person or group will behave and act themselves without right and wrong of action. This is important for the decision-making process. In addition to this, each person has their own values and ethics, and this leads to a person's behavior all life (56).
Ethics is a core element of all healthcare professionals and nurses. Hence, it plays an important role in nurses' perception of the overall quality of care towards patients to improve health improvement. Nursing history shows that ethics has been a fundamental part of the profession for many years (57). Some factors such as individual character and responsibility affect professional ethics in nursing practice. Also, nursing literature stated that professional commitment is not only increasing quality for nursing practice but also understand their decisions and lead to the better observance of professional ethics by nurses (58).
The International Council of Nurses (ICN) - Code of Ethics
Nurses are one of the health providers responsible for giving care to patients based on ethical issues. They are faced with ethical dilemmas and circumstances involving conflicting values and interests. They must know ethical knowledge to fulfill their job effectively and give safe care with convenient ethical and legal issues in the field of healthcare in today's changing world (59). Because ethics seek for the best way to taking care of patients within the best nursing performance including skills and knowledge. Besides this, it is necessary to must be familiar with ethical codes and the essentials of ethical decision-making.
According to American Nurses Association (ANA), professional nursing is defined as not only protect and promote health but also prevent illness and injury within the care of individuals such as all ages, families, groups, and populations. (60). And ethics is the main element of all healthcare professions including nursing and it plays an essential role in influencing patients' health improvement.
An aspect of ethics should be implemented in every course in the university. Because ethics is an essential topic to teach at the university level, especially in the medical departments.
Ethical aspects must be addressed carefully and, nursing and medical students must understand the effects of ethical obligation in health care (61). Ethics must be located in the three special areas: 1) Educational experiences for the development of students' learning, 2) contributing to patient care, 3) health promotion using a population-based approach. Hence, health care students can have practical and theoretical knowledge within the comprehensive education plan in the university. Herewith, students must know the ethical values and think about solving ethical dilemmas (62).
The codes of ethics have been adopted for many professions in recent decades and it is fundamental guidance, including nursing in many countries. The first international code of ethics for nurses (ICN) approved by the Council of National Representatives (CNR) in 1953.
In the nursing profession, nurses often try to find ethical reasoning to evaluate action and results and also decided which actions are right or wrong. The code of ethics, which is published by the International Council of Nurses, helps directly nurses in everyday decisions when giving care to patients. With regard to the ICN Code of Ethics for nurses, nurses have four fundamental responsibilities which are universal. These are: to promote health, to prevent illness, to restore health, and to alleviate suffering. After all, the most recent revision of the ICN code completed in 2012 (63). In addition to the fundamental responsibilities, the four principal elements within
ICN Code involve the standards of ethical conduct such as nurses and people, nurses and practice, nurses and profession, and nurses and co-workers (38). To achieve this, a code of ethics must be understandable and adopted by all nurses including all aspects of their work (39).
Nurses' awareness of their values is a core part of nursing care. With ethical conduct, nurses make ethical decisions more effectively and they can perform as professionals such as clinical nurses, researchers, and policymakers.
To conclude, it is important to clarify that defining nursing ethical values & principles can have a clearer understanding of nurses on an international level. Also, nurses must know the Code of Ethics within their profession and be aware of their own integrity with deep ethical thinking. Because ethical considerations in nursing represent a true integration of the art of patient care and must be included in care.
The Main Principles in Health Care
Ethical values are universal rules to identify what kind of actions and motivations are valued based on a practical basis (64). In addition to this, the ethical decision requires considering values and some kind of perspective. Having an ethical awareness can identify to empower nurse to act as a professional on behalf of providing patient safety. Beauchamp and Childress stated four principles:
• Autonomy
Each patient has their own values and ethics to make decisions based on a person's behavior, beliefs, and that affects a person's life. Autonomy is referred to as a basic human right and is one of the principles of ethics. It is important that patients should be allowed to make their own choices about treatment that patient's healing process, recovery, and well-being, without exposure to any pressure. Because every person has a right to make informed decisions about treatment, and the right to refuse treatment, medication, surgery, or medical interventions (56).
• Beneficence
Beneficence plays a major role in all of the health care, and it is one of the fundamental ethics. Also, it has an integral function in health care. An understanding of this ethic code can lead all professionals while delivering patient care with high standards. All health care providers have the responsibility of treating the patient properly and help them to do the best for the
patient in each situation besides that, they have to minimize the harm that they can cause to patients and promote good health including the patient (65).
• Non-maleficence
The ethical principles of non-maleficence have been directly associated with not harming the patient. According to part of the Hippocratic Oath, it is important to consider the physician's duty goes beyond the prevention of harm (66). Besides that, all health care professionals are obligated to protect the well-being of their patients. Meanwhile, patients have a right to no harm. The physician must know which treatment is proper for the patient, also which one is harmful.
• Justice
The literal meaning of justice characterized by ensures both the fair and equitable treatment of all people, (67). It must be holistic and integrated by ethnics by care. Because patients have equal rights in healthcare and the distribution in healthcare must be based on justice.
To summarize, these principles are significant to understand the current approach to ethical evaluation in health care. All healthcare professionals must conduct ethical decision- making processes. Because ethical principles guide to get the result in maximum beneficence and minimum harm which could be avoided by directly associated with improving health and patient outcomes.
1.3.Medical, Legal and Ethical Issues in Nursing The Professional Nursing and Regulation
In the profession of nursing, regulation is an important component in ensuring safe and competent practice. Laws and rules are part of the nursing practices to supply safe care. Nurses must be aware of their rights and obligations in interaction with other nurses, other health care workers, patients, and families of patients (68).
The legal aspect of nursing has become more effective with written policies and some practices.
This provides better healthcare for nurses. Because regulation plays a big role in quality and patient safety. Also provides guidance for critical thinking and nursing professions (69). In brief, ethical principles must be covered by the law and some regulations based on nursing. To give an example, the Code of Ethics for Nurses, the Helsinki Declaration, and the Nuremberg Code's some parts include law with legal standards (70).
Knowledge on Legal and Ethical Aspects in Patient Care among Nurses
Nurses face many legal, ethical, and medical issues during work life. Nowadays legal and ethical problems associated with health care day by day. Therefore, nurses should know about legal issues in their work lives. It is essential to understand the law and its effects on working and also practicing (71). Because the legal aspects of nursing have an impact on caring between nurses and patients. The Nurses’ Code of Ethics is a guide for nurses to have ethical decision-making. But in the literature, there are some limitations to ethical issues within the lack of information and this can cause ethical challenges faced in the nursing field (62). In addition to this, to have safe and high-quality nursing practice is possible to conduct with knowledgeable legal aspects. Moreover, laws, rules, and regulations have an impact on the relationship between nurse and patient (72).
To summarize, health services are one of the most regulated sectors that ensure the safety of health workers and patients. There are some ethical guidelines that provide an explanation of ethical values, obligations, and regulations in the health system. In addition, ethical principles serve as a guide for achieving new applicable laws, rules, and regulations.
1.4.Perception of Ethical Issues by Physicians and Nurses Ethical Issues Faced by Physicians
Ethical problems routinely arise in the hospital. Physicians manage ethical issues in their practical life, and it is difficult to deal with them almost every day and in a different situation (73). Because medicine is a complex area that physicians must be aware of the ethical and legal aspects of medicine that involve their professional role within the health care system. However, they still need to understand the ethical principles, then they also need the practice to develop themselves. Because there is still something missing in education, training, or practicing. The ethical aspects of the physician-patient relationship are shaped by such factors in the medicine area. This relationship is very crucial, and it can affect both sides (74).
In Turkey, physician-patient encounters are still under the control of the paternalistic tradition on some issues during recent years. The Ministry of Health (MOH) has implemented some changes in inpatient care in the health care system. With this implementation, patient involvement increases in treatment-related decision-making in the health care system lately (75).
To summarize, ethical statements developed primarily for the benefit of the patient. A physician must recognize a responsibility to patients first. In addition to this, the relationship between a patient and a physician is based on ethical responsibilities and it can be enhanced in managed care.
Ethical Issues Faced by Nurses
Nurses have struggled with ethical issues in inpatient care for long years. Indeed, Florence Nightingale stated ethical duties of confidentiality, the importance of communication in her notes (53). Likewise, ethical principles and duties are located in the nursing profession.
However, in today's healthcare environment, ethical issues in nursing are becoming complex and nurses are often faced with an ethical dilemma in clinical practice and research (76). This situation is becoming complex that nurses feel under pressure. Some studies stated that nurses' socio-demographic background including sex, education level, experiences of years may affect ethical issues depend on this situation. Most of the time nurses affect by ethical issues in a bad way. It can occur increased burnout and decreased work motivation between health care providers and patients (77).
In Turkey, clinical decision-making is one of the essential elements of nurses, but they keep back in the background in decision-making the process when it compares with physicians (78).
This reason can cause that they feel unworthy and inadequate in the clinical area. Besides this, nurses face some ethical issues including medical, technological, and clinical administration.
For this reason, nurses fell under pressure and the pressures causing nurses to act unethically in the health care system (79), (80).
To summarize, ethical problems will always exist in health care. The natures of the physicians’ and nurses’ professional roles show that they identified more ethical problems in the areas for which they are responsible.
Ethical Issues between Physician and Nurse Collaboration
Interprofessional collaboration in the healthcare system includes different professions and it affects the delivery of health services including patient care. In a particular area, physicians and nurses play a significant role in the patient care process (81). Although nursing and medicine are different fields and they have their own code of ethics, they must interact with each other. Because each profession takes part in patient care and patient outcomes differently (82). Some research has shown that several factors may influence the physician-nurse relationship and collaboration:
• Poor Communication
Teamwork is one of the most important components of providing care of patient safety and health care quality (83). Perceptions of care quality may change by profession, but the care must be patient centered. It means that both professions have to focus on patient care. The way of communication is another important component of giving care to patients. Communication breakdown among physicians and nurses can lead to increase medical errors (84) and poor patient outcomes, decreased patient length of stay at the hospital, death, poor quality of care, and poor patient satisfaction (85). Some researchers stated that physicians and nurses face a lack of communication daily because of treatment. It can cause unclear drug orders can put patients at risk with the wrong drug and wrong dosage even the wrong patient’s name (84).
These misunderstandings and inconvenient communication affect physicians' and nurses' job satisfaction, a lack of autonomy, higher possibility of intention to leave the job (86).
• Not Recognizing Their Roles
Nurses and physicians both are important health care professionals to give the patient the right care with high quality. However, they mostly do not recognize their professional roles and it is a barrier to the establishment of good relations between these professions (87).
According to Nightingale, much of the conflicts derived from the historically dominant role of the physicians and having authoritative power and the subservient role of the nurses (88). Also, nurses have difficulty in communication and recognizing their roles with physicians and it can lead to increase tension among them. Such smaller triggers can cause stress including job issues (89). Each profession has to recognize their professional roles with some boundaries to maintain their proper relationship and productive work environment.
• Nurses Autonomy
Professional autonomy is important for understanding nurses’ roles in delivering patient care and also job satisfaction (90). Nurses' professional knowledge and values, communication, and interpersonal skills are beneficial for clinical decision-making with reliable sources of information, as well as working in a supportive environment (91). There are some studies showed that nurses were dissatisfied with their work and they suffered from burnout (92). In addition to this, nurses may encounter burnout due to their innate desire to put others before themselves. In the workplace, nurses want to show their professional autonomy in everyday interactions, and they want to see respect from the physicians (93). Each health organization must have goals such as including nurses' autonomy in the decision-making process.
• Physician's Dominance
A hierarchy is an organizational structure in which items are ranked according to levels of importance (94). This importance between physician and nurse is reflected in professional roles, decision-making process, information sharing not including nurses. Even today, physicians do not include nurses in the decision-making process, and ignoring the professional autonomy of nurses is an important reason for job dissatisfaction and lack of motivation to remain in nursing (95). Most physicians think that they make a significant decision to give patients better care. Also, their educational background is very comprehensive comparing with nurses. Therefore, physicians believe that professional dominance' displayed by physicians.
In Turkey, nurses are not able to participate in the information-sharing process by physicians.
Also, nurses' perceptions of the clinical decision-making process are poor. The communication problems between physicians and nurses are mostly derived from the lack of shared information and approach to each other. Lack of understanding, poor work ethic, and inappropriate attitudes are the main problems with physicians (96). All these factors can harm interprofessional relationships. Nurse's feelings of inequality with physicians can change the perception of the nurse's role and the nurses can lead to burnout (97). Moreover, nurses are not satisfied with their actual jobs because of workload issues, organizational policies, and procedures (98).
Overall, these factors can lead to a decrease in nurses' willingness and ability to keep on working in Turkey.
To summarize, having good communication among physicians and nurses is essential for a cooperative relationship. The right approaches and perceptions may cause better understanding and work more effectively. Furthermore, understanding each profession's role is crucial for patient care. It can decrease the possibility of errors in the workplace. Beyond, medical dominance which is taken by physicians can influence nurses' decision-making and nurses' authority
1.5.Association Between Nurse-Physician Collaboration and Patient Outcomes
Collaboration between healthcare professionals especially nurses and physicians is significant to achieve better patient outcomes, quality of health care, and improve patient safety (99). The positive relationship among them delivers in a safe, effective, and sustainable way and it can be solved patient problems with high quality (100). Because each profession has its own job definition such as different treatment planning by physicians or different nursing care plans. Because this relationship based on patient-centered care (101). According to the American Nurses Credentialing Center, even if not an effective relationship is not always working, patient care is a shared responsibility between them (102).
On the other hand, existing literature showed that educational background, years of working experience, gender (103), age clinical training, organizational culture, and policies, overlapping responsibilities, hospital workload, and individual behavior (104) and differences can cause an increase of medical errors and poor outcome (85). Patients may at risk because of those misunderstandings and misinterpretations. Also, this collaboration is not only for the patient's outcomes but also to assume their role and positive interactions both physicians and nurses.
To summarize, both physicians' and nurses' job descriptions such as duties and responsibilities must be well described. Because a clear job description can address a proper work environment, enhance individual and team skills. It has a direct impact on patient health outcomes, patient satisfaction, and preventive care.
1.6.Empirical Research in Medical Ethics and Collaboration
Empirical research refers to the collection and analysis of the data based on observation and or experimentation in the field (105). Before any data are gathered, the scientist must control all the data which are come from the research (106). It is significant to know the data and gathering information to support the research. Besides this, medical ethics has been derived from medical practice. Physicians must pay attention to the legal, ethical, medical norms of researching including human subjective with international and standard norms (107).
In recent years, literature has been shown that empirical research in ethics with particularly medical ethics has been accelerating (108). In spite of the fact that there are some empirical ethics that depend on the research including principles, behaviors, and approaches (109).
Additionally, that research may be included social science, access the information, wider populations, literature review, and professional institutes (110). Empirical research can show which factors are effective or practice. This approach not only can analyze the practical situation but also determines the moral concept of empirical research (111). Medical ethics derived from empirical research. Morality is the basis of ethics and understanding of attitudes, beliefs, and informed decisions must include in the practice (112), and medical ethics has more comprehensive theories and principles comparing with the moral concept of theories (113).
Over the course of many years, ethical-empirical research has been becoming popularize by some researchers such as epidemiologists, sociologists mostly in the field of ethical aspects (114). For instance, these aspects including medical ethics are based on bioethics (115), and some ethics related to research (116). Empirical research must be harmonized with different fields to get a better result with different approaches (117).
Further, medical ethics is one of the daily realities of medical practice. Understanding the empirical research in medical ethics, the demands of working with different groups of people such as health care professionals, researchers, and academicians from different fields are particularly important to increase collaboration (118). Because it requires various disciplines and approaches to study productively. However, there are some discussions about medical ethics. These discussions can be defined as analyzing increased ethical problems that arise from the practice of medicine and learning the standards of the medical profession (119).
Nevertheless, every healthcare professional has an ethical principle to do the execution of their duties as members of the profession (120). Conversely, empirical research on medical ethics
including healthcare professionals describes insights gained from describing the value-contexts of health care practices emphasizes how physicians and nurses work ethically (121).
To summarize, empirical research can provide a framework and a general view of the consequences of standard norms. Further, empirical research can illustrate the moral concept of theories within a solution. Hence, empirical research in medical ethics must be identified with ethical and normative principles that how to analyze and interpret the empirical findings.
2. METHODOLOGY
2.1.Design, Setting, and Period of Study
A cross-sectional study anonymously was conducted to determine physicians' and nurses' perceptions about their collaboration and the factors that influence it. The study is conducted at Başkent University Ankara Hospital as a private hospital in Turkey in September 2020.
2.2.Sample and Sampling
The sample for this study was randomly selected from the Başkent University Ankara Hospital. All eligible nurses and physicians were invited to participate in the study.
After receiving the approval of the Chief Physician Başkent University Ankara Hospital, a pilot study was performed with 20 nurses and 20 physicians. The data was collected at two different points in time (one-week interval). Convenience sampling was used. All departments in the hospital were divided into surgical science and internal sciences in the questionnaire. A sample size of 350 was calculated within 95% confidence interval and a sample error of 5%. A total of 350 questionnaires were distributed to the respondents and 280 questionnaires were received (response rate - 80%).
2.3. Research Instrument
An authorized and standardized questionnaire was used in this study. The data was collected with the ''Medical and nursing staff respondents' perception of the nurse-physician relationship'' questionnaire (El-Hanafy, E, Y., 2018).
A questionnaire is elaborated to evaluate the assessment of ethical issues in the inter- professional physician-nurse relationship. The questionnaire consisted of two sections: (1) Part A of the research instrument consists of the items which socio-demographic characteristics of respondents; (2) Part B of the research instrument consists of the set of questions used to estimate respondents' perception of the physician-nurse relationship.
The questionnaires included 31 questions with using open-ended and closed-ended questions.
The opinions of the respondents regarding the assessment of ethical issues will be estimated using a 5-point Likert scale: '' (1) = strongly disagree'', '' (2) = disagree'', '' (3) = Neutral'', '' (4)
= agree to ''(5) = strongly agree'' respectively.
The questionnaire was printed distributed as a hard copy and give to physicians and nurses and asked them to complete it. Responses to items on the scale are scored in the same direction. The original questionnaire was in English. The scale was first translated from English to Turkish separately by three bilingual linguists, medical and other professionals. Another expert reviewed the Turkish translations together for inconsistencies with the original English form and minor revisions were suggested in some areas and one Turkish version of the scale was created.
2.4. Statistical Data Analysis
The obtained data were coded and analyzed with a statistical program „IBM SPSS 26“.
Data were presented in form of frequencies, means, standard deviation, and percentage for quantitative variables. T-test was used to make a comparison and find the p-value between the two groups. Chi-Square test of independence was used to determine if there is a significant relationship between among two groups and 𝑝 < 0.05 was considered statistically significant.
Person correlation analysis was used for the assessment of the interrelationships among quantitative variables.
2.5.Research Ethics
The study is conducted after getting permission from the Bioethics Centre at Lithuanian University of Health Sciences and Study participation for physicians and nurses was approved by the Chief Physician of Başkent University Ankara Hospital. The study's aim was explained to all participants prior beginning of the study. All gathered information was kept in confidentiality and generalized so to prevent any identification of research participants.
The study project was presented to The Bioethics Centre of Lithuanian University of Health Sciences and the approval was received in 2020-06-17. (No. BEC-VS(M)-125.)
3. RESULTS
3.1.Socio-Demographic Characteristics of Respondents
To analyze the social and demographic characteristics of our respondents it was used Descriptive Statistics data analysis tool. The socio-demographic characteristics of the respondents are summarized in table 1. Table 1 shows that both physicians’ (40,9%) and nurses’
(69,6%) age distribution has between 20-30 years old. Although a large number of male physicians (70%) have experienced less than or equal to 10 years, the large number of both male nurses and female nurses have experienced less than or equal to 10 years (88%, 75,61%
respectively) (Table 3).
Table 1: Socio-demographic characteristics of respondents (N= 280).
Characteristics Physicians Nurses Total
N (%)
N (%) N (%)
Gender
Male 60 (45.45%) 25 (16,89%) 85 (30,4%)
Female 72 (55,55%) 123 (83,11%) 195 (69,6%)
Age (years)
20-30 54 (40,9%) 103 (69,6%) 157 (56,1%)
31-40 42 (31,8%) 30 (20,3%) 72 (25,7%)
41-50 25 (18,9%) 14 (9,5%) 39 (13,9%)
51-60 9 (6,8%) 1 (0,7%) 10 (3,6%)
61-70 2 (1,5%) — 2 (0,7%)
Level of Education
High school — 36 (24,32%) 36 (12,9%)
Bachelor 5 (3,79%) 98 (66,22%) 103 (36,8%)
Master 92 (69,7%) 14 (9,46%) 106 (37,9%)
Doctorate 35 (26,51%) — 35 (12,5%)
Years of Experience
(in years)
≤ 10 85 (64.39%) 115 (77,7%) 200 (71,4%)
11-20 33 (25%) 23 (15,54%) 56 (20,0%)
21-30 10 (7.58%) 10 (6,76%) 20 (7,1%)
31-40 4 (3.03%) — 4 (1,4%)
Department
Internal Medicine 81 (61,36%) 73 (49,32%) 154 (55,0%) Surgery 50 (37,88%) 60 (40,54%) 110 (39,3%) Intensive Care Unit 1 (0,76%) 15 (10,14%) 16 (5,7%)
Total 132 (100%) 148 (100%) 280 (100%)
While the fewer number male physicians have experienced more than 30 years, nurses do not have experiences more than 30 years (Table 3). On the other hand, While the great majority of both female physicians (72,22%) and nurses (53,66%) had worked in internal medicine, most of both male physicians (51,67%) and nurses (48%) had worked in surgery, the fewer number of both female physicians (1,39%) and nurses (7,32%) had worked in the intensive care units (Table 2). This shows that most of the respondents were dominantly female for both physician (55.55%) and nurse (83.11%) groups.
Table 2: Socio-demographic characteristics of respondents between department and profession Department
Physician Nurse Total
M F M F M F
Internal 29 (48,33%)
52
(72,22%) 7 (28%) 66 (53,66%) 36 (42,35%)
118 (60,51%)
Surgery 31
(51,67%)
19
(26,39%) 12 (48%) 48 (39,02%) 43
(50,59%) 67 (34,36%) Intensive 0 (0,00%) 1 (1.39%) 6 (24%) 9 (7,32%) 6 (7,06%) 10 (5,13%)
Total 60 72 25 123 85 195
Table 3: Socio-demographic characteristics of respondents between profession and working year
Working Year
Physician Nurse Total
M F M F M F
≤ 10 42
(70,00%) 43 (59,72%) 22 (88%) 93 (75,61%) 64 (75,29%) 136 (69,74%) 11 - 20 11
(18,33%) 22 (30,56%) 2 (8%) 20 (16,26%) 13 (15,30%) 42 (21,54%) 21 - 30 4 (6,67%) 6 (8,33%) 1 (4%) 10 (8,13%) 5 (5,88%) 16 (8,21%)
31 - 40 3 (5%) 1 (1,39%) 0 0 3 (3,53%) 1 (0.51%)
Total 60 72 25 123 85 195
Moreover, the large majority of physicians (69.7 %) had a master’s degree, and nearly one-quarter of the physicians (26.51%) had a doctorate degree, and the least percentage of
physicians (3.79%) had a bachelor’s degree. In contrast, nearly one-quarter of the nurses (24.32%) had a high school degree, the majority (66.22%) of nurses had a bachelor’s degree, and the least percentage of nurses (9.46%) had a master’s degree (Table 1).
3.2.Differences in Mean Value Evaluating Professional Relationship
The Chi-Square test (χ² test) was used to analyze if there is an association between variables. For a Chi-square test, 𝑝 < 0.05 was considered statistically significant. While the majority of nurses (43,93%) are female, the majority of physicians (21,43%) are male (Figure 1). It indicated that there is an association between profession and gender (χ²=26.924, df=1, p=0.000).
Figure 1: The relationship between profession and gender (p=0.000)
The large majority of physicians (32,86 %) had a master’s degree. In contrast, the majority (35%) of nurses had a bachelor’s degree (Figure 2). There is an association between profession and level of education. (χ² =26.924, df=3, p=0.000).
Majority of physicians (30,36%) and nurses (41,07%) have experienced less than or equal to 10 years (Figure 3). There is no statistical significance between the relationship between profession and working year. (p=0.021, Fisher’s Exact Test). The profession is completely independent of gender.
Figure 3: The relationship between profession and working year (p=0.021)
Figure 4: The relationship between profession and age (p=0.000)
While the age distribution of physicians by position decreases regularly, the age distribution of the greater part of nurses (36,79%) and physicians (19,29%) by position is between 20 and 30 years old (Figure 4). There is a significant association between profession and age (χ²=27,973, df=4, p=0.000).
Figure 5: The relationship between gender and working year (p=0.068)
Figure 6: The relationship between working year and age (p=0.000)
